Improving cataract services: better access, better outcomes, better value

The three pillars of combatting vision impairment due to cataract are: • Output – the number of cataract operations performed, often expressed as the cataract surgical rate (the number of cataract operations per million population per year) • Outcome – the results of cataract surgery, i.e., what percentage of eyes achieve good vision after a cataract operation, and the complication rate • Outlay – how much an eye service needs to spend to provide cataract surgery (which will affect how much patients have to pay).

A lthough highly effective treatment for cataract has been available around the world for several decades, it remains the leading cause of avoidable blindness. It is completely unacceptable that millions of people are deprived of their right to sight due to a condition that can be cured with a safe, fast, and cost-efficient procedure.
The articles in this issue show that improvement doesn't only rely on new techniques, drugs, or equipment. Instead, improvement is also the result of a coordinated effort by everyone in the eye team to provide a patientcentred service.
The three pillars of combatting vision impairment due to cataract are: • Outcome -the results of cataract surgery, i.e., what percentage of eyes achieve good vision after a cataract operation, and the complication rate • Outlay -how much an eye service needs to spend to provide cataract surgery (which will affect how much patients have to pay).
Improving cataract services means addressing all three of these. With a balanced approach to output, outcome, and outlay, it is possible to see major improvements in all three areas.
The second partnership is with the community. There are numerous examples of engagement with the community in this issue of the journal, and in our previous issue on community engagement. These partnerships can involve working together to promote and publicise cataract services. Community partners may be community organisations, local government, businesses, media organisations, faith-based agencies, educational institutions, and patients who are happy with their cataract surgery. Partnerships can involve collaboration in the delivery of services -using a school as a venue for an outreach eye clinic during the weekend, for example. Members of the community can also be trained to identify cataract patients and to support follow-up care after cataract surgery. The greater the involvement of the local community, the more likely it is that patients will know about the services and trust their local eye care provider. Think about your clinic's links to the local community. Are there avenues of collaboration that you haven't explored? Are there strong local organisations that could help to promote or deliver cataract services? What about cost sharing models, such as health insurance?
The third partnership is with hospital management. In hospitals and eye clinics, in both high-and low-income countries, there needs to be a balance between income generation and cost-containment required by managers, and the scope of service provision by clinicians. This can sometimes lead to conflict: as clinicians, we want to provide the best possible services for everyone who needs them, regardless of the cost; however, managers have a responsibility to balance the books

About this issue
Unoperated cataract remains the leading cause of blindness and moderate to severe visual impairment worldwide, affecting 94 million people globally. Addressing this urgent need requires a coordinated effort by everyone in the eye team to provide a patient-centred service, increase access to cataract surgery, and improve visual outcomes after surgery. A balanced approach to outcome, output, and outlay -as well as a focus on partnerships -is key, and this issue of the journal offers some helpful pointers and examples.

Effective Cataract Surgical Coverage (eCSC): improving quality, output and access
and to ensure that the clinic has enough funds to pay salaries at the end of the month. If we want to treat more patients (increase output), and obtain the best possible results (improve outcomes), we need to acknowledge that this will cost more (increased outlay), and we will need managers to approve the additional expenditure. Fortunately, all parties can achieve their goals. If the number of operations is increased, the unit cost per operation will decrease. This will bring in more profit that can be reinvested in improved services, or in subsidies for patients who would otherwise be unable to afford surgery. Increased outlay is therefore entirely compatible with greater financial sustainability.
The fourth partnership is with eye care personnel -the eye team. The most valuable resource an eye clinic has is its workforce, and we need to ensure fair and transparent human resource policies in which all staff members contribute responsibly in their defined roles and are treated fairly and without favouritism. It takes time and effort to build this kind of partnership -one that is based on trust and understanding of the different but complementary needs and objectives of managers, support personnel, and clinicians. Have you ever spoken to the clinic's receptionist, or the hospital administrator, outside of a formal meeting in the workplace? If not, maybe it is time to start to build these partnerships.
We have a duty to reduce vision impairment caused by cataract, and this issue of the journal offers some pointers. If we keep in mind the essential messages of partnership, and balancing output, outcome, and outlay, then we will be successful.
Governments and international organisations, like the World Health Organization (WHO), need to be able to evaluate how well eye health services are doing in reducing avoidable blindness. In the past, they looked just at quantity: the number of people in a population who had undergone cataract surgery, using a measurement known as Cataract Surgical Coverage (CSC).
This compared the number of people who had undergone cataract surgery to those who needed surgery (both operated and unoperated), and expressed this as a percentage. CSC did not measure the quality of surgery: how well the patients could see after their cataract operation.
To ensure that quantity and quality are both measured, ministries of health, WHO and other institutions increasingly want to know the Effective Cataract Surgical Coverage (eCSC): the number of people who can now see well after cataract surgery, expressed as a percentage of those who needed surgery (both operated and unoperated).
In 2021, all WHO Member Countries agreed to a new global target: increasing eCSC by 30 percentage points by 2030. 1,2 This target sets a new standard for the visual outcome of cataract surgery: a presenting visual acuity (PVA) of 6/12 or better, which is more difficult to achieve than the previous standard: PVA of 6/18 or better. 1 Increasing eCSC requires that eye units provide high quality surgery -which means routine measurement and reporting of surgical outcomes is now more important than ever. Recording who is coming for surgery is also vital so that we can ensure we are providing equitable access for all, including women and people with disabilities.
Providing people-centred cataract surgery, through outreach services and integration with existing health care services at primary level (as detailed in our recent issues on primary eye health care 3 and community engagement 4 ) will also help to improve patients' awareness and acceptance of surgery, as well as their ability to physically reach the services they need.

With thanks to Elmien Wolvaardt, Jacqui Ramke and Heiko Philippin.
Unless otherwise stated, authors share copyright for articles with the Community Eye Health Journal. Illustrators and photographers retain copyright for images published in the journal.
Unless otherwise stated, journal content is licensed under a Creative Commons Attribution-NonCommercial (CC BY-NC) license which permits unrestricted use, distribution, and reproduction in any medium for non-commercial purposes, provided that the copyright holders are acknowledged.

ISSN 0953-6833
Disclaimer Signed articles are the responsibility of the named authors alone and do not necessarily reflect the views of the London School of Hygiene & Tropical Medicine (the School). Although every effort is made to ensure accuracy, the School does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use.
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South Asia Edition supported by:
C ataract is the leading cause of blindness globally. The VISION 2020 programme prioritised increasing the number of cataract operations performed and improving service coverage. More recently, the World Health Organization (WHO) World Report on Vision emphasised integrated people-centered eye care. 1 Among the ten key messages of The Lancet Global Health Commission on Global Eye Health was that high quality eye health services are not always delivered. 2

Why does quality matter?
One of the top five challenges in eye health today is improving cataract surgery services: their quality, equity and access. 3 WHO defines quality of care as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and describes good quality services as effective, safe, peoplecentered, timely, equitable, integrated, and efficient. 4 Good quality services attract more patients, which is vital for improving demand for, and uptake of, cataract services -which is important if we are to address the surgical backlog in many countries.
But how can we improve? Monitoring clinical outcomes is an important first step. If you are already doing this, the next step is to look at patients' experience and how that can be improved.
The case study below, although imperfect, shows that speaking to patients can highlight improvements that can be made at low cost while still significantly improving patients' experiences. Ideally such surveys should be repeated annually so that improvements can be tracked.

Case study: Learning from our patients
City Eye Hospital is a busy day surgery centre in the city of Nairobi, Kenya that sees around 200 patients every day. Most cataract operations are done by phacoemulsification under topical anaesthesia. In 2022, we decided to find out more about our patients' experience of the service, with the aim of finding out how our service could be improved.
Because we were short on staff time, we looked at questions researchers in other countries had asked their patients about their experience before, during and after cataract surgery 5 and created a patient satisfaction questionnaire that we thought would be reasonably relevant in our setting. Our aim was not to produce published research, but rather to inform ourselves about how we could improve.
Over three days in June 2022, a customer service staff member asked patients waiting in different areas in the hospital whether they were willing to be interviewed. If a patient agreed, and had received cataract surgery within the previous month, the staff member asked them to rate, on a scale of 1 to 5, how satisfied they were with a set of statements about their care (see panel). The statements included aspects of care before surgery, on the day of surgery, and after surgery. A total of 62 patients completed the questionnaire over the three days.
Patients who were 'satisfied' or 'very satisfied' were graded as being happy with the service and those who were 'unsatisfied' or 'very unsatisfied' were graded as being unhappy with the service.
Patients were happy about most aspects of the service, and no-one was 'very dissatisfied' with any aspect, which was encouraging. All were happy that they could see after surgery: 77% were very satisfied and 23% were satisfied.
However, we were keen to find out what aspects patients were less satisfied with, as that showed where we could make improvements.
The results show that the patients' main source of dissatisfaction is not their clinical care. Patients were unsatisfied with the following: • A lack of provision of a cataract surgery brochure before surgery that they or a family member could read (86%) • Pain during surgery (58%) • Lack of accessibility by phone if they had questions before surgery (54%) • Long waiting times in the queue to open a file (22%), to see the doctor (22%) and when waiting for your turn on the day of surgery (23%).
Only pain management required a change in clinical practice. One possible solution would be to train nurses to give sub-Tenon's blocks prior to surgery, and we are currently investigating this.
We have also addressed patients' dissatisfaction with the absence of a contact number -we now give them a number to call if they have concerns before or after surgery. Shortening waiting times and providing written information about cataract surgery are more difficult to address, but we are looking at ways this can be done. Patient-reported outcome measures (PROMs) are a potential solution to this dilemma. 4 PROMs are short questionnaires given to patients before and after surgery to ask about their own perception of their vision and the impact of their vision on their quality of life; this is expressed as a numerical score.

Lessons for the future
Although perception of vision and quality of life are subjective (i.e., individual to each patient), PROM questions are developed through a robust process of research, testing, and mathematical analysis, which means that the scores produced when the questionnaire is administered before and after surgery can provide a reliable measurement of the improvement experienced by each patient. Creating PROMs requires the input of patients during development to ensure they consider patients' visual needs, which will vary depending on factors such as patients' level of literacy or the need to be able to drive.
PROMs put patients' perception of their own vision at the centre. This encourages clinicians to listen to patients and helps them to understand how patients' vision impacts their quality of life, which in turn permits health care professionals to develop services that meet the needs and expectations of patients -a very desirable outcome.
C ataract surgery can be a frightening prospect for many patients. Hearing from others in their community who are happy with the results can have a significant impact and increase the overall uptake of cataract surgery in that community. To achieve this, we need to deliver cataract services that are successful in the opinion of the most important people: the patients.
But how can we know whether our patients are happy, and what matters to them?
A patient-centred approach has two components: 1 Patients' experience of the cataract service before, during and after surgery. This can include comfort/ pain, cleanliness, communication, and many other aspects of care. We cover this in more detail in another article in this issue.
2 The visual outcome of surgery, which surgeons need to know so they can check their surgery is of good quality. This will be the main focus of this article.

Visual outcome
The success or failure of cataract surgery has traditionally been assessed by measuring a patient's presenting visual acuity after surgery.
Visual acuity is an essential benchmark for the quality of cataract surgery. We should all aspire to meet the WHO's new recommendation that 80% of eyes operated on should have a presenting visual acuity of 6/12 or better after surgery. 1 In fact, by measuring and publicly reporting the visual acuity outcomes of cataract surgery, the United Kingdom's National Health Service was able to significantly improve outcomes by introducing a National Ophthalmology Database Cataract Audit in 2014. Likewise, tools such as the free BOOST cataract app (https://boostcataract.org) allow surgeons in low-or middle-income settings to monitor cataract outcomes and receive feedback without incurring additional costs. 2 Publishing these data publicly can improve outcomes and boost public confidence -which in turn improves the uptake of cataract surgery. 3 In most low-income settings, patients tend to come for surgery when their cataract is already advanced. For them, a presenting visual acuity outcome of better or equal to 6/12 (the new World Health Organization benchmark) is highly satisfactory.
However, in high-income settings, the excellent visual acuity outcomes of cataract surgery, combined with the availability and affordability of surgery, has led to early uptake of services. For example, at least a third of patients undergoing cataract surgery in the UK have pre-operative visual acuity of 6/12. For them, visual acuity is a less useful indicator of the success of surgery. 3 Visual acuity is usually measured by asking patients to read black letters on a white background at six metres -a task that few patients ever need to do in real life. Patients with higher pre-operative visual acuity will be more interested in their visual function: how the operation has improved their ability to do everyday The hospital routinely monitors the outcomes of surgery in order to improve quality and improve standards, which has enabled it to develop an excellent reputation. Most patients believe the surgery offered is affordable. Manual small-incision cataract surgery costs 1,200 Nepalese rupees per eye (less than US $10), which is approximately 10% of the monthly minimum wage in both Nepal and the neighbouring Indian state of Bihar. As a result, SCEH no longer actively promotes its cataract surgery services in Nepal, because there is no perceived need to do so. In India, however, there are cataract motivators in the community who recruit patients and help them by arranging bus travel to the hospital.

How is high output achieved?
The whole process is highly organised; every staff member, from surgeon to security guard, is clear about their role in the patient journey.
Each surgeon works between two operating tables simultaneously. By the time a surgeon has removed the first patient's cataractous lens and tied the conjunctival suture, the next patient, on the adjacent table, is ready for their lens to be removed.
Surgeons use the 'Fishhook' surgical technique 1 to deliver the nucleus, and the entire procedure takes just 3-4 minutes to perform on the fully prepared patient.

Clinical and surgical team
The clinical team consists of two general consultant (senior) ophthalmologists and five consultant ophthalmologists who are also subspecialists: a paediatric ophthalmologist, a cornea subspecialist, a glaucoma subspecialist, and two retina subspecialists. All the subspecialists split their days between cataract surgery and their own subspecialty.
There are also seven anterior segment fellows: recently graduated ophthalmologists from Nepal who are at different stages of a rigorous 2-year in-house training programme in cataract surgery (see panel).
Ophthalmic assistants at SCEH have an extended role. They perform a detailed eye examination of each patient and take an ocular and systemic history. The level of difficulty of the operation and the likelihood of complications are then discussed with the senior supervising surgeon, who decides which patients to assign to which trainees, based on their level of experience. This approach ensures high quality and fewer complications.
SCEH also employs eye health workers (EHWs) who are trained to perform pre-operative checks and prepare patients for surgery. This includes giving the peribulbar block, applying the bridle suture (superior rectus muscle traction suture), placing the speculum, performing peritomy (opening the conjunctiva), and cauterising the highly vascular scleral tissue.

High-volume cataract surgery in Lahan, Nepal
The efficient, team-based approach to cataract surgery practiced at Sagarmartha Choudhary Eye Hospital increases output and reduces outlay by ensuring that everyone's time is used efficiently -thereby making surgery more affordable.

Managing quality
Every three months, cataract operations are audited and staff present and discuss difficult/challenging cases to improve practice.
If a surgeon or trainee surgeon encounters complications, a senior surgeon will step in if needed. The surgeon responsible is asked to follow the patient's progress closely and give a presentation that includes a discussion of the complication and how it could have been avoided and/or better managed (this can include reviewing video recordings). The trainee surgeon may then be supported with closer supervision if needed.
Cataract surgical outcome is measured on the first day after surgery, at the end of the first month after surgery, and at the three-month follow-up visit. At the one-month follow-up, more than 60% of all cataract patients have uncorrected visual acuity of 6/18 or better.

Outlay
Ordering consumables in bulk (made possible due to the high volume of surgery) helps to keep the costs down. Most surgical instruments are sterilised and re-used, e.g., keratome and crescent blades (typically can be used for five cases), Simcoe cannulas (cleaned then steam sterilised and reused).
The greatest saving in terms of outlay is due to the efficiency with which patients move through the eye care system. The systems developed at SCEH, such as training eye health workers to prepare patients and give anesthesia, and setting up the operating theatre so one patient is being prepared while the surgeon is still operating on another patient, reduce the time the patient is in theatre, which means that everyone's time is used more efficiently. This reduces the overhead costs per patient and therefore the overall outlay, which supports SCEH to offer surgery at an affordable price.

Sustainability
SCEH has a separate outpatient department for patients on higher incomes and offers a range of eye services, including phacoemulsification cataract surgery. Income from this department subsidises low-income patients. SCEH also benefits from donor agencies who support the costs of equipment, human resource development, and surgical consumables.

Supporting women
Even though women and girls in Nepal have a greater burden of blindness than men and boys, they are less likely to visit eye hospitals, for a variety of reasons. 2 SCEH monitors uptake of cataract services separately for male and female patients, and has put in place measures to make the facilities female friendly, for example by offering separate registration counters, queues and toilets for men and women, an enclosed breastfeeding space, and a female counsellor for female patients. At present, around 3% more cataract operations are performed in women than in men.

The authors would like to thank Astrid Leck and Elmien
Wolvaardt for their contributions to this article.
Cataract surgery trainees, known as anterior segment fellows, undergo a rigorous two-year training programme.
Candidates must be ophthalmologists registered with Nepal's Medical Council and undergo a written exam and interview at SCEH before being considered for the programme.
The successful candidates must also pass the SCEH protocol exam before being eligible to examine patients in the outpatient department (OPD). T he Aravind Eye Care System (AECS) has an annual output of over 300,000 cataract operations a year through its network of 14 hospitals. More than 60% of all operations are subsidised or at no cost to the patient, and they are performed using the manual small-incision cataract surgery (MSICS) technique.
Thanks to advances in surgical techniques and intraocular lens (IOL) technology, cataract surgery can now restore sight and address refractive error. Given that many patients may not have access to spectacles, or be able to afford them, it is important to achieve a good presenting visual acuity after surgery. In recognition of recent evidence about the impact of mild vision impairment (visual acuity of <6/12 to 6/18) on the everyday functioning of individuals, 1,2 the World Health Organization now recommends a threshold for presenting visual acuity after cataract surgery of 6/12 or better. 3 As part of Aravind's ongoing cataract quality improvement strategy, we set out to address postoperative presenting visual acuity by testing a different approach to biometry. Biometry is the process of taking measurements of the eye to predict the power of IOL that would be needed by each patient. Accurate prediction of IOL power is one of the major factors that determines presenting visual acuity after cataract surgery. The accuracy of a biometry service is measured by recording the percentage of patients for whom the difference between the target refraction (estimated during biometry) and the refraction achieved after surgery falls within a specified range of prediction error; this is expressed as a spherical equivalent, in dioptres (D).
Our quality improvement process includes these steps: 1 Identify the problem (ask: what needs to change?) and gather baseline data on outcomes/outputs before changes are made 2 Set standards based on agreed benchmarks 3 Decide on the methods or equipment needed to make an improvement 4 Introduce changes and train personnel 5 Measure impact 6 Gather data to drive a process of ongoing improvement.

Identifying the problem and gathering baseline data
Until 2012, IOL power was calculated using contact or applanation ultrasound biometry methods as this is easy and quick to perform, especially in high-volume services ( Figure 1). However, because this method involves direct contact with the cornea, compression of the cornea is possible, which can cause reading errors.
Aravind uses an electronic medical record-keeping system called CatQA to monitor and continually improve outcomes and processes. When we analysed the CatQA data from our hospitals, we found that just 40.4% of the patients who had undergone ultrasound biometry and MSICS had a prediction error within ± 0.5D, and 85% had a prediction error within 1.0D.  In 2021, despite carrying out fewer operations, on more advanced cataracts (due to the COVID-19 pandemic), we significantly exceeded the NHS benchmarks with 68.2% and 94.9% of patients within the ±0.5 D and ±1.0D prediction error, respectively (Table 1).
There was a corresponding improvement in the proportion of patients achieving better postoperative visual acuity once we started using immersion biometry. The proportion of patients who had uncorrected postoperative visual acuity of 6/18 or better improved from 63.0% in 2012 to 83.9% in 2021 (Table 2). Similarly, the proportion of patients with uncorrected visual acuity of 6/12 and better increased from 31.0% in 2012 to 59.8% in 2021 (Table 2).
To conclude, this process of patient-centred quality improvement promoted patient safety, treatment effectiveness, and efficient use of resources. The constant monitoring of outcomes provided the information necessary to continuously improve, refining the quality processes in ways that were often not expensive (e.g., using better IOL calculation formulae). The first step in the process is identifying where opportunities exist to improve, which will be different for each institution.
We would encourage everyone involved in cataract surgical service provision to be in this constant quality improvement cycle, as this helps to achieve the best outcomes for patients, irrespective of the volume of cataract surgery.

Setting standards
We decided to base our standards for the accuracy of biometry on the benchmark set by the UK's National Health Service (NHS): a prediction error within ±0.5 D in 60% of patients, and within ±1.0D in 90% of patients. 4

Finding the methods or equipment needed to make an improvement
There is good evidence 5 that immersion ultrasound biometry performs better than contact ultrasound biometry and can be used in all cataract types (although optical biometry performs better than ultrasound overall, it doesn't work in advanced cataract -which is more typical in low-income settings such as ours).
Based on this evidence, and our available human and financial resources, we took the decision to convert from applanation ultrasound biometry to immersion ultrasound biometry in all 14 eye hospitals.

Introducing changes gradually
Immersion biometry was implemented between 2013 and 2018, in just a few hospitals at a time, by first upgrading the equipment and then retraining the staff members who perform biometry. Training was structured and staff were closely monitored. By the end of 2018, al 14 hospitals were performing immersion ultrasound biometry ( Figure 2).

Measuring impact
To measure impact, we collected data about the accuracy of IOL power prediction a year after introducing immersion ultrasound biometry and again in 2021. The impact of the change was evident when we compared this with the baseline data from 2012 (Table 1). Following the adoption of immersion ultrasound procedure across all 14 hospitals, we found that, of the 153,868 patients who had undergone immersion biometry, 54.6% now had a prediction error within ± 0.5D (up from 40.4%) and 96.0% had a prediction an error within ±1.0D (up from 85%).

Ongoing data gathering and evaluation
We continued to routinely monitor the prediction error and make improvements where needed. (Figure 3), using a process of outcome monitoring and quality improvement.
Other opportunities for quality improvement, including using better IOL calculation formulae and offering staff members further biometry training, were responsible for some of the additional improvements seen between 2019 and 2021 (Table 1). Outcome monitoring C ataract is the leading cause of avoidable blindness worldwide. 1 Since the burden of cataract blindness is greatest in the communities who are least able to afford eye care, cost is a major barrier to patients accessing cataract surgery. [2][3][4] The financial barriers to patients accessing cataract surgery may be greater in rural areas, as additional travel, accommodation, and food costs are often incurred. 5 Lack of access to cataract surgery can be financially devastating, often resulting in reduced economic potential because of vision impairment. 6 Thus, designing more accessible and affordable cataract services is essential for tackling inequalities and overcoming poverty.
The aim of this article is to discuss high-volume cataract surgery as a strategy for lowering the cost of cataract surgery per patient. High-volume cataract surgery does not have an absolute definition, but is often considered as a service that carries out significantly more cataract operations than centres in the surrounding area .7 Cataract surgery costs can be divided into the costs of consumables (such as intraocular lenses, medication, anaesthetics, and disposables) and the costs of infrastructure and salaries (Figure 1) . . 7 Each cataract operation uses approximately the same amount of consumables, therefore the yearly cost of consumables varies in line with the number of cataract operations performed in that year.
The cost of infrastructure and salaries is typically larger than the costs of consumables and must be paid regardless of the number of cataract operations performed each year. Examples of infrastructure and salary costs include staff salaries, equipment, cleaning, and building maintenance.
Although increasing the yearly number of cataract operations (the cataract volume, or output) will increase the total yearly cost of consumables, the cost of infrastructure and salaries remains fixed. By carrying out more operations per year, the infrastructure and salary costs -which can make up the bulk of the total cost of surgery in smaller centres -is therefore shared between more patients, bringing down the cost per patient for an individual cataract operation. Increasing the cataract volume also enables further reductions in the cost per operation through taking advantage of 'economies of scale' such as bulk purchasing of consumables: by buying a large number of items at once, lower prices could be negotiated, further reducing the cost per operation.

Growing your surgical output
A key assumption of high-volume cataract surgery is that most cataract services have unused capacity. Estimates of East African cataract services suggest that, although surgeons currently perform fewer than 300 operations each per year, they could perform 500 to 800 per year if improvements were made to management systems. 8 This would have to be matched by increasing the number of patients who come for surgery, as detailed elsewhere in this issue and the previous issue on community engagement. Since staff salaries are a major fixed cost, optimising the number of operations performed per surgical day by theatre teams is an effective strategy for reducing the cost per eye. 8,9 Figure 3 is also based on our hypothetical example, and shows how the cost per operation reduces as the number of cataract operations per year increases. Table  1 shows how the costs per operation is calculated for 500 and 800 operations, respectively.

Reducing the costs per patient by increasing the volume of cataract surgery
When eye units increase their cataract output, a small increase in the outlay (for consumables and IOLs) can drastically increase income and/or reduce costs for patients. The cost of consumables and IOLs are the same for each operation. The total cost per year will therefore rise as the number of operations increases.
The yearly costs associated with infrastructure and salaries remain the same whether doing 300 or 800 operations each year.

Infrastructure and salaries Consumables
operation.
• If the annual cataract volume is 800 cataract operations per year, the outlay is $61.25 per operation ($30 for consumables + $31.25 for infrastructure and salaries). If the hospital charges $85 for cataract surgery, it makes a profit of $23.75 from each operation. Table 2 shows the outlay and profit on an annual basis for a surgical volume of 500 and 800 operations per year. For 500 operations per year, the annual profit is $2,500, and for 800 operations per year, the profit is $19,000 per year.
Increasing the cataract output by 300 operations per year requires an additional outlay of $9,000 to cover the cost of the IOLs and consumables. But this is more than made up for by the increase in income from £2,500 to £19,000: an increase of £16,500. Additional profits generated by increasing the number of cataract operations could be used to subsidise patients who would otherwise struggle to afford surgery, or could be reinvested in services to make them more sustainable.  Hypothetical example: a cataract service with an annual output of either 500 or 800 operations Here is a hypothetical example of a cataract service where the yearly infrastructure and salary cost is $25,000 per year, and the cost of consumables for one cataract operation is approximately $30. The total cost of one cataract operation can be calculated by dividing the total yearly cost of infrastructure and salaries ($25,000) by the number of operations per year, then adding the consumables cost (see the formula in Figure 2). T he burden of vision impairment and blindness is borne disproportionately by women around the world. 1 In Nepal, the age-adjusted prevalence of bilateral blindness (presenting visual acuity <3/60 in the better eye) is 2.4% in women and 2.1% in men. 2 Despite this, fewer women than men come to eye hospitals; they are more likely to visit rural outreach clinics where services are limited. 3 A 2010 policy brief on eye care equity in Nepal highlighted that gender disparity in eye care is persistent, profound, and pervasive. 4 To better understand the barriers women faced, Tilanga Institute of Ophthalmology carried out formative research in 2016 which concluded that the cost of eye care services and the lack-of female-friendly care were the major barriers. This was supported by qualitative exit interviews with women about the specific changes that would make eye health facilities more female-friendly for them.

Number of cataract operations per year
Based on these findings, Tilganga Institute of Ophthalmology, with support from the Fred Hollows Foundation (FHF), conducted a pragmatic trial of strategies to promote access to eye care for women in remote and marginalised areas in five districts of eastern and far-western Nepal, including the hill regions and the terai (lowlands). The strategies were delivered through two intervention packages, from 2018 to 2020.
The first intervention package focused on the delivery of a set of strategies that collectively sought to address the 'awareness' and 'acceptability' dimensions of access, by enhancing women's experience of care and their awareness of services. This included: • making eye health facilities female-friendly by setting up separate queues and toiles for men and women, as well as an enclosed breastfeeding space The second intervention package focused on the additional benefits associated with reducing the non-medical, out-of-pocket costs associated with eye care, thereby addressing the 'affordability' dimension of access. This included: • free eye treatment and free surgery for low-income and marginalised female patients referred by female community health volunteers, as well as for women referred at outreach camps in all intervention districts • financial support for travel, food, and accommodation for the patients and for one family member accompanying each patient.
Data were collected at baseline (before the packages were implemented) and at the end of the study period, using a mixed method approach at the level of service providers and the community. The quantitative results were analysed using the difference-in-differences method, which compared the changes observed at the intervention sites with that of the control. The results were further supported by qualitative findings that were transcribed, reviewed, and analysed manually by identifying themes and categories.
After one year of the intervention, it was observed that -in the intervention sites -awareness-raising activities for women increased their knowledge about cataract. The work of female community health volunteers at the community level also led to an increase in women's self-reported autonomy in decision-making about accessing eye health care, and women cited female community health volunteers as a preferred source of eye health information. Most importantly, travel barriers decreased after intervention, with the provision of financial support to cover the travel costs of accessing eye care. However, the interventions could not increase women's access to cataract surgery at distant tertiary eye hospitals, with women citing household responsibilities as the main barrier. Instead, there was a surge of female service seekers in the outreach camps that were closer to their homes.
Based on the findings from the trial, the following measures could be adopted by eye health service providers to reduce the gender disparity in eye care access in other parts of Nepal and in countries with rural, marginalised populations, and where women have to depend on their male counterparts for decision-making.

At the institutional level
• In all eye hospitals, there should be a dedicated team for gender and eye health programmes led by a gender focal person with specific terms of reference. The overall responsibilities of the focal person would be to ensure the delivery of gender-responsive services, support policies to enhance gender equality, arrange periodic training for staff on gender issues, and so on. clinical services (including cataract surgery) by female patients.
• Periodic review of the records of female patients (regular patients, as well as those referred by female community health volunteers and via outreach camps), including those of women from marginalised groups, can provide useful feedback to hospital management teams. Disaggregated data by gender, ethnicity, and area can be used to monitor interventions and reduce disparities in eye care access and delivery.
• Regular communication should be established with community clinics in the catchment areas to collect information regarding women's use of eye care services, including difficulties faced while providing eye services to female patients.
Eye care providers should provide regular updates about women's eye health needs, expectations, issues, and challenges.

At the community level
• Regular communication should be established with local governments and local health facilities to promote community-based eye health programmes and strengthen the referral mechanism in collaboration with local female community health volunteers (where available) and other stakeholders.
• The integration of cataract referral programmes with other local health programmes, where appropriate and feasible, can reduce staff effort, increase coordination, reduce the time spent on programme activities, and possibly increase the coverage area.

At national level
In Nepal, there is a strong structural network of primary health care centres across all the administrative units. This study showed that women could be reached and encouraged to use eye care services through the community. Thus, integrating eye care services into existing primary health care programmes will increase the availability of eye care at the grassroots level, to which women have easier access.

CASE STUDY: INDIA
S itapur Eye Hospital was set up in 1927 in Sitapur, in the Indian state of Uttar Pradesh. The hospital began cataract services in 1935, 1 providing much-needed community eye care for many decades. However, there followed a period of decline in eye care services, with the hospital's cataract output reducing to just 2,000 operations per year in 2009. The hospital's extensive buildings also degraded over time.
The prevalence of cataract in Uttar Pradesh is high because of poor access to surgery. 2 High quality, high-volume eye care centres are therefore needed, and Sitapur Eye Hospital (SEH), with its large physical infrastructure and recognisable brand value, had the potential to increase its cataract output to better meet the eye care needs of the population.
A team was formed in 2009 to do just that. They found that the key challenges were as follows: • a shortage of eye care personnel with the right level of skills in the right areas • a lack of systems to monitor and improve quality • not enough patients coming in for surgery • a lack of proper counselling for patients needing surgery, and a lack of effective tracking of patients, e.g., by sending follow-up reminders • a lack of outreach activities • a shortage of funds • staff attitudes that compromised patient care.
Over the next 13 years, these challenges were addressed through improvements in the following areas.

Systems, infrastructure, training, and quality
Improvements have included the installation of better equipment, training of ophthalmic personnel, renovation of the operation theatre, and putting in place better systems flow and processes. Information and hospital management system (IHMS) software was installed to electronically record the demographic and clinic data of patients. Outpatient processes were streamlined. All clinical and administrative protocols were also aligned to the country's standard operating procedures; these were strictly followed and monitored to avoid any medical errors, such as cluster endophthalmitis. The visual outcomes of cataract surgery were assessed using Cataract Quality Metrics, a benchmarking software programme. Infrastructure and quality improvement is a continual process now, which is built into our organisational culture.
The academic/training programmes that we now offer includes a Bachelor of Optometry degree, a Masters in Ophthalmology degree (with an annual intake of 15 students), clinical fellowships in ophthalmology and optometry, and training courses for ophthalmologists, optometrists, and ophthalmic assistants.

Collaborations
Organisations such as Aravind Eye Care System,

Improving cataract output in India: a joined-up approach
Improvements in outreach, demand generation, training, and quality control yielded a 15-fold increase in cataract output in just over a decade at Sitapur Eye Hospital.
Sightsavers India, CBM, and Orbis, as well as the Indian government -through health schemes like the national programme for control of blindness and visual impairment, 'Rashtriya Bal Swasthya Karyakram' (a national programme to protect and promote the health of children) -are collaborating with us to improve service quality, offer training, and improve service delivery; they are also providing financial support.

Increasing patients' access to surgery
Sitapur Eye Hospital conducts comprehensive eye care outreach camps where we identify cataract patients in rural and low-income communities. Everyone selected for cataract surgery at the camps is offered free eye surgery, spectacles, medicines, transport, and food. During the COVID-19 pandemic, door-to-door screening and mobile van-based services were created to reach the community. For non-surgical eye conditions, twenty well-equipped vision centres have also been established in eight districts; these enable communities to have easier access to eye care in their local neighbourhoods.

Finances
Initially, Sitapur Eye Hospital's chief medical officer, who is responsible for teaching and administration, helped to generate income by performing phacoemulsification using premium lenses, glaucoma surgery, and paediatric surgery. This subsidised the cost of providing care to patients who would otherwise be unable to afford surgery.
Finances now come from multiple sources. Sitapur Eye Hospital has set up a three-tier paying system for patients: paid services for those who can afford to pay in full, subsidised services for those unable to pay the full fees, and free treatment for those unable to pay at all. The ratio of paying to free patients is 30:70. The hospital also receives funding from non-governmental organisations (which support their special outreach activities), via government reimbursements and medical insurance, and from the sale of spectacles and medicines. All of this has enabled us to become financially self-sustaining.

Results
As a result of these efforts, Sitapur Eye Hospital has increased its output from 2,000 cataract operations in 2009 to 31,000 operations in 2021, with no episodes of cluster endophthalmitis and 74.8% of patients achieving corrected visual acuity of 6/18 or better. We operate on 700 to 800 children for cataract annually and attend to all sub-specialty cases. According to the demographic data collected using our IHMS, the male-to-female ratio of cataract patients is 50:50. Because of our outreach services, eye care is now reaching more villages, which is improving access to services for women, children, and disabled people, on their doorstep.

Looking to the future
The Sitapur Eye Hospital model is a self-sustainable one, both financially and in terms of human resource needs. Infrastructure and quality improvement is now a continual process, built into our organisational culture. The aim is to perform 100,000 cataract operations annually by 2030, to continue to provide equitable eye care for all, to develop specialties in ophthalmology, and to upgrade training and research facilities on an ongoing basis.